Glenn D. Steele Jr., MD, PhD, President and CEO
Albert Bothe Jr., MD, Chief Quality Officer
Ronald Paulus, MD, MBA, Chief Technology & Innovation Officer
Geisinger Health System
___________
This contribution from Geisinger Health System continues the PA-PSRS Patient Safety Advisory series on leadership perspectives of patient safety. Geisinger leaders’ buy-in and support helped to drive evidence-based changes in the provision of care to patients undergoing coronary artery bypass graft surgery, a process improvement that has also yielded cost benefits.

—John R. Clarke, MD, Editor
___________

Almost two years ago, the leadership of Geisinger Health System began challenging its clinicians to further improve the quality of care being delivered to its patients in central Pennsylvania. One of the early areas to receive attention was elective coronary artery bypass graft surgery (CABG).

Data from the Pennsylvania Health Care Cost Containment Council showed that Geisinger was already performing very well.  Despite that, Geisinger’s cardiac surgeons began meeting to review newly updated professional guidelines from the American Heart Association and the American College of Cardiology, which were based on well-founded studies in the medical literature. Over several months, the surgeons, working with Geisinger’s performance improvement team, reviewed the literature and studied its existing processes. As in most institutions, they found preference-based variations in technique, equipment, and steps within the flow of patient care that each surgeon believed was best for patients. Led through the review by the chief of cardiac surgery, the seven cardiac surgeons came to agree on 40 individual steps representing evidence-based best practices that should be provided to each and every CABG patient. Because of the evidence-based nature of its care guidelines, Geisinger has termed this approach as ProvenCare^SM.

The cardiac surgery workflows at the two Geisinger hospitals where CABGs were performed (Geisinger Medical Center in Danville and Geisinger Wyoming Valley in Wilkes-Barre) were redesigned or revised to help ensure that all 40 elements were reliably provided. This included new templates for use during both office visits and hospital care, standardized order sets, and real-time reminders in the electronic health record. Office staff, residents, physician assistants, and nursing staff were all brought into the work redesign since the 40 elements spanned the time from the initial office evaluation and continued through the cardiac rehabilitation stage.

In the first month of the pilot phase, the redesign team found that all 40 of the agreed-upon elements were only being provided 57% of the time. With the aid of the performance improvement team, the surgeons further imbedded some of the principles of reliability science (e.g., redundancy, automation, delegation) into the daily workflows. Shortly thereafter, reliability was achieved. All 40 elements were being provided 100% of the time, month after month. The initial experience with the clinical elements was recently published in the October 2007 issue of the Annals of Surgery.¹ Compared to a matched group of patients in the immediately preceding time period, length of stay and total hospital charges had decreased. Other metrics have also improved, although the already excellent results made it difficult to show a statistical difference in the initial time frame. Redesigning the system to reliably deliver evidence-based care has improved quality while consuming fewer resources.

Further prompted by its interest in reshaping the existing reimbursement models to explicitly recognize quality of care, Geisinger has offered a 90-day warranty for patients who undergo a ProvenCare CABG. Under most healthcare reimbursement arrangements in the United States, providers usually receive additional pay‑ments for the care of complications related to their ser‑vices. Geisinger has offered a single price that covers both hospital and physician services from the preoperative phase through any additional care related to the CABG for 90 days at its facilities. Geisinger believes that by reliably providing at least the 40 elements of care, it will minimize the likelihood of any complication. If any complications of the CABG surgery were to occur, Geisinger would absorb the extra cost.

Focus groups of patients and employers find the commitment to each and every one of the 40 steps in the care process to be appealing. As Donald Berwick, MD, president of the Institute for Healthcare Improvement, commented in the New York Times (May 17, 2007) about ProvenCare, “Getting everything right is really, really hard.” Payers and insurers find the approach intriguing. By having a single, all-inclusive price for CABGs, Geisinger reduces the variability in claims related to this particular service by offering a single charge for the entire episode of care. Furthermore, one of the 40 elements is a commitment that the surgery will only be performed on those patients who meet the nationally recognized indications, so that there is no question about the appropriateness of the procedure.

Geisinger is in the process of developing similar ProvenCare programs in other areas. Pilot projects have begun in total hip replacement surgery and in cataract surgery. Geisinger is also adapting the same principles of process reliability to the care of several chronic diseases. Geisinger believes that reliably delivering evidence-based care will ensure quality and control costs.

Notes

1. Casale AS, Paulus RA, Selna MJ, et al. “ProvenCare^SM”: a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg 2007 Oct;246(4):613-23.